Waner, Gene #53Z.
NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Gene Roger Warner Male
Date of Death Age If Veteran of U.S. Armed Forces,
October 20,2018 39 War or Dates
J- Place of Death Hospital, Institution or
5 City, Town or Village Moreau Street Address 167 Ferry Blvd,
`p Manner of Death El Natural Cause ID Accident El Homicide El Suicide li ❑Undetermined El❑Pending
Circumstances Investigation
U Medical Certifier Name Title
Q Dr.Michael Sikirica MD
Address
Albany,NY 12205
Death Certificate Filed District Number ,— Register Number
City, Town or Village Moreau (/ 3( 5 3
,'❑Burial Date Cemetery or Crematory
November 21,2018 Pine View Crematorium
'❑Entombment Address
®Cremation Quaker Road,Queensbury,NY
Date Place Removed
Z Removal and/or Held
0 �and/or Address
5 Hold
ti Date Point of
❑Transportation Shipment
41 by Common Destination
4 Carrier
❑Disinterment Date Cemetery Address
El Renterment Date Cemetery Address
Permit Issued to Registration Number
' Name of Funeral Home Carleton Funeral Home,Inc. 00281
"". Address
68 Main Street,Hudson Falls,NY 12839
E Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
2 Address
w
EL Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued / //?/// ? Registrar of Vital Statistics (1),(eW C i--R.—
(signature)
District Number L/$(p 2., Place 7 /Jv) o j` /.n oa/ e 4 GA--
A.
I.
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Z `'
ill Date of Disposition III Bill Place of Disposition e.. � 7c'ii
2 (address)
Ce (section) lot number) (grave number)
p' Name of Sexton or Person incharge of Pr ises 4 t.1. )kell
Z' (plea print
tli
1 Signature Title LiV41+cru1
(over)
DOH-1555 (02/2004)